Send a nurse now or we will call 911.

[SoCalRN1970]

Here it is. The threat.

One of our beloved patients called today with concerns regarding a finding at his doctors. Why would he go? Because "she wanted too!~" The MD found the patient tachycardic in the 150's. No chest pain. NO shortness of breath. Nobody including the patient wanted "agressive ER". Except the cardiologist. He suggested 911.

This conversation took place at early am. Patient and family wished to have NO aggressive treatment but needed a visit. Instructed them I'd be there between 1200 and 1300. Arrived at patients home at 1245 and found heart rate 60's irregular, but that is standard findings. Found out though patient has what appears to be a bad respiratory infection, possible pnuemonia... congested.

Patient tended too. New orders, training, all disciplines notified. Called family from out of the area. and.. they said they called the hospice at 1230 telling them if I didn't show up asap that they were going to call 911. I reviewed that threat and found that the family had no intention of doin 911. But "knew it would get me out there faster".

OI vey.. the day is done thank god.

[tewdles, RN]

Calls like that rarely get the oncall nurse to the house sooner, in my experience. We always reinforce that patients may seek aggressive care at any time, but that some care would require that they revoke the hospice benefit in order to pursue it (any care directly related to the hospice dx but not included in the hospice POC).

It is always challenging when patients and families try to manipulate the staff rather than to work collaboratively to meet the patient needs. Making threats are just that, manipulation, and your team should try to come up with a plan to address that behavior if possible.

Good luck.

[jeannepaul, BSN]

or how about, if you don't do so and so, or give me this or that, Im going to change to a different hospice. I hear that alot esp. from nursing home employees.......if you don't start cc, we are going to change, we don't have time to give the med every 2 hours.

[tewdles, RN]

That is when the manager needs to visit. Talk with the patient and family. Discover IF three IS a way provide care. But, honestly, it is okay for people to choose another hospice. I enjoy it when it happens in our favor, but that door swings both ways. As a manager I have actually made the call for the family to the other agency and got the ball rolling during the visit.

Just like we counsel our bereaved, you have to let go of the person and embrace the love and the memories.

[ErinS, BSN, RN]

But, honestly, it is okay for people to choose another hospice. I enjoy it when it happens in our favor, but that door swings both ways. As a manager I have actually made the call for the family to the other agency and got the ball rolling during the visit.

Just like we counsel our bereaved, you have to let go of the person and embrace the love and the memories.

Amen! We have also gently encouraged patients to look into another hospice if we are not meeting their "needs", which are usually more like demands. Another conversation I have had with families is they can certainly call 911, but it will be their responsibility to pay the bill. Medicare won't cover it, and an ER visit is not in the hospice plan of care.

[tewdles, RN]

Of course, sometimes a visit to the ER is in the POC...

[mschelee, MSN, RN]

How can a hospital visit be in the POC? my clinical mgr freaks out if a patient goes to er and signs them off service. This is regardless of if it is related to the hospice dx or not. She says we will get the bill. I've been told if it unrelated, they ( the hospital) can bill under a modifier, but how to you write it into the POC?

Mschelee

[tewdles, RN]

The POC can include supporting the patient in different palliative treatments or anticipated emergent care.

If we have an end stage cardiac patient, for instance, who is not a DNR, has an implanted defibrillator, and WILL call 911 - we discuss that expectation and our goals/interventions related to that. We create a plan for the team should the patient actually call 911 before we can help the patient and family to set goals consistent with the dignity and comfort they desire.

We practice putting appointments for unrelated and related problems alike in the POC.

So, my POC should include all of my pts' appts with PCP, radiology for palliative tx, appts for palliative infusions, or hydration, etc.

[SuesquatchRN, BSN, RN]

It is still astonishing to me that someone can be on hospice and a full code.

[SoCalRN1970]

It happens... and it happens alot. Patients in California do not need to be a DNR to be on hospice, but you bet your sweet backside, they are pushing and pushing and pushing it all the time.

[mrr5745]

or how about, if you don't do so and so, or give me this or that, Im going to change to a different hospice. I hear that alot esp. from nursing home employees.......if you don't start cc, we are going to change, we don't have time to give the med every 2 hours.

This is my biggest pet peeve! I've had nursing homes ask if we were going to start CC when the patient was still alert, talking, eating and drinking with perfectly normal vitals. Seriously? Sometimes I just want to scream stop being so lazy and do your job! Arrgghh!!!

[tewdles, RN]

If families threaten to change hospices I make sure that the MSW has provided them with a comprehensive list of agencies and discusses it with them.

If a family is that unhappy we are glad to let them go as it is unlikely that we will be successful in making them happy. (even tho we are the best hospice in the area)